The vasopressin type 2 receptor (V2R) plays an important role in water homeostasis. Mainly expressed in the collecting ducts of the kidney, V2R activation by the antidiuretic hormone arginine-vasopressin (AVP) leads to water reabsorption, resulting in a decrease urine output. More than 200 mutations in the V2R gene have been link to the aetiology of the congenital form of nephrogenic diabetes insipidus (cNDI), resulting from a receptor loss-of-function. In contrast, three recently identified mutations have been shown to cause a gain-of-function of the V2R leading to the nephrogenic syndrome of inappropriate antidiuresis (NSIAD). The work presented herein is focussed on a better understanding of the molecular determinants leading to the loss- or gain -of-function of V2R mutants. More than 50% of missense mutations affecting the V2R were shown to hamper the receptor’s ability to adopt its native conformation and to cause its intracellular retention by the endoplasmic reticulum quality control system. We thus looked at the role of N-glycosylation and calnexin (Cnx) in the maturation process of mutant V2R, and their importance for receptor rescue by pharmacological chaperones (PC). Our results have shown that N-glycosylation is required for Cnx binding to the receptors and that the duration of this interaction is correlated to the severity of the misfolded state of the mutant. The importance of N-glycosylation and to sugar-mediated interactions in the maturation process of a given V2R mutant was found to be an intrinsic property, as it had no significant repercussion on the mild phenotype-associated Y128S mutant, while it completely abolished maturation of the W164S mutant, associated with a severe phenotype. Moreover, we have shown that pharmacological chaperoning can occur at different steps during the maturation process, according to the mutant studied. These mutant-specific differences indicate that the biosynthetic processing of mutant V2R is highly influenced by the nature of the mutation itself and could partially explain the variations in the clinical outcome severity among NDI-causing mutant V2Rs.
Although a functionality rescue of W164S and Y128S mutants was obtained upon exposure to PC, it is not the case for all V2R mutants with a maturation defect. The V88M-V2R was found affected both in its maturation and its affinity toward AVP. In this case, and despite a significant increase in maturation and cell surface expression, the PC treatment led to a further loss in the receptor’s affinity for AVP, preventing its activation at physiological AVP concentrations.
The R137C and R137L mutants are endowed with a high constitutive activity leading to NSIAD. Stunningly, substitution of this arginine by histidine (R137H) was associated with cNDI. These three mutant V2R were found to share many characteristics, of which a compromised maturation and elevated spontaneous desensitization. The only difference between these mutants relies on their constitutive activity levels. The PC used in our studies is also an inverse agonist, but failed to reduce the constitutive activity of the R137C/L mutants, entailing a ‘locked’ active conformation. Instead, the chaperoning property of the compound led to an increase in the number of constitutively active receptor at the cell surface. We have thus proposed the use of AVP as a treatment, as it was shown to cause receptor’s endocytosis without promoting their activation, leading to a reduced active receptor number at the cell surface.
We have identified a new gain-of-function mutation affecting the V2R, the first not involving arginine 137. The F229V substitution was shown to confer high constitutive activity to the receptor, but unlike the two other NSIAD-causing mutants, it does not undergo elevated spontaneous desensitization. The observation that inverse agonists are efficient at inhibiting the constitutive activity of the F229V mutant is an important discovery since the unfruitful attempts obtained with the other constitutively active mutants led some investigators to the erroneous conclusion that inverse agonists were not useful for the treatment of NSIAD.
Taken together, these findings underline the ‘individuality’ of V2R mutants and the importance of their functional characterization in order to bring personalized therapeutic strategies for patients with cNDI or NSIAD, and to develop new therapeutics adapted to the patients’ needs.